BACKGROUND: Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP).
PURPOSE: To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence.
STUDY DESIGN: Systematic review; Level of evidence, 2.
METHODS: A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included "injection," "corticosteroid," "platelet-rich plasma," "autologous blood," "tennis elbow," "lateral epicondylitis," and "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.
RESULTS: Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE.
CONCLUSION: The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term.
BACKGROUND & AIMS: Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
METHODS: A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
RESULTS: Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
CONCLUSION: This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
OBJECTIVE: This article is aimed at critically evaluating the evidence from systematic reviews (SRs) of spinal manipulation in patients with pain. Design: The study was designed as a SR of SRs. METHODS: Four electronic databases were searched to identify all relevant articles of the effectiveness of spinal manipulation for pain. SRs were defined as articles employing a repeatable methods section. RESULTS: Twenty-two SRs relating to the following pain conditions: low back pain (N = 6), headache (N = 5), neck pain (N = 4), any medical problem (N = 1), carpal tunnel syndrome (N = 1), dysmenorrhea (N = 1), fibromyalgia (N = 1), lateral epicondylitis (N = 1), musculoskeletal conditions (N = 1) and nonspinal pain (N = 1), were included. Positive or, for multiple SR, unanimously positive conclusions were drawn for none of the conditions mentioned earlier. LIMITATION: Publication bias as a well-known phenomenon may have been inherited in this article. CONCLUSION: Collectively, these data fail to demonstrate that spinal manipulation is an effective intervention for pain management.
OBJECTIVES: The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition.
DESIGN: Four electronic databases were searched to identify all relevant systematic reviews of the effectiveness of spinal manipulation in any condition published between 2005 and January 2011. Reviews were defined as systematic, if they included an explicit and repeatable inclusion and exclusion criteria for studies.
RESULTS: Forty-five systematic reviews were included relating to the following conditions: low back pain (n=7), headache (n=6), neck pain (n=4), asthma (n=4), musculoskeletal conditions (n=3), any non-musculoskeletal conditions (n=2), fibromyalgia (n=2), infant colic (n=2), any medical problem (n=1), any paediatric conditions (n=1), carpal tunnel syndrome (n=1), cervicogenic dizziness (n=1), dysmenorrhoea (n=1), gastrointestinal problems (n=1), hypertension (n=1), idiopathic scoliosis (n=1), lateral epicondylitis (n=1), lower extremity conditions (n=1), pregnancy and related conditions (n=1), psychological outcome (n=1), shoulder pain (n=1), upper extremity conditions (n=1) and whiplash injury (n=1). Positive or, for multiple SR, unanimously positive conclusions were drawn for psychological outcomes (n=1) and whiplash (n=1).
CONCLUSION: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition.
Acupuncture is commonly used for pain control, but doubts about its effectiveness and safety remain. This review was aimed at critically evaluating systematic reviews of acupuncture as a treatment of pain and at summarizing reports of serious adverse effects published since 2000. Literature searches were carried out in 11 databases without language restrictions. Systematic reviews were considered for the evaluation of effectiveness and case series or case reports for summarizing adverse events. Data were extracted according to predefined criteria. Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported. Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.
OBJECTIVE: Several systematic reviews (SRs) have assessed the effectiveness of acupuncture for rheumatic conditions, often with contradictory conclusions. Our aim is to provide a critical evaluation and summary of these data. METHODS: Electronic searches were conducted in 15 databases to locate all SRs on acupuncture for rheumatic conditions published since 2000. Data were extracted by the authors according to pre-defined criteria. RESULTS: We found 30 SRs that met our inclusion criteria. They related to the following rheumatic conditions: FM, low back pain, lateral elbow pain, musculoskeletal pain, orthopaedic diseases, OA, RA, shoulder pain, frozen shoulder, neck disorder, AS and sciatica. Their conclusions were in several instances contradictory. Relatively clear evidence emerged to suggest that acupuncture is effective for OA, low back pain and lateral elbow pain and ineffective for FM and RA. CONCLUSION: Many SRs have recently been done. Only for OA, low back pain and lateral elbow pain is the evidence sufficiently sound to warrant positive recommendations of this therapy in routine care of rheumatic patients.
Systematic reviews of acupuncture have tended to support its use, but few applied rigorous inclusion criteria. We tested the credibility of conclusions of systematic reviews of acupuncture published since 1996 by applying rigorous inclusion criteria. Reinterpretation used randomised and double blind trials with valid outcomes or design, and with information available from at least four trials or from 200 patients. Qualified support for acupuncture was originally reported in 12 out of 35 systematic reviews, and strong support was found in another six. Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomised, double blind studies. Six reviews with more than 200 patients in randomised, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.
OBJECTIVE: The purpose of this review was to determine how effective different classes of analgesic agents are in the management of chronic pain.
METHODOLOGY: The literature search identified five systematic reviews and 18 randomized controlled trials to provide evidence about systemic drug treatment for chronic pain.
RESULTS: Studies in the systematic reviews were mainly of low back pain, and studies in the randomized controlled trials were mainly of fibromyalgia. Other studies investigated of rheumatic pain, musculoskeletal pain, chronic low back pain, and temporomandibular pain. Classes of analgesic agents reviewed were antidepressants, nonsteroidal anti-inflammatory drugs, muscle relaxants, opioid analgesics, and a number of miscellaneous agents.
CONCLUSIONS: For chronic pain, opioid analgesics provide benefit for up to 9 weeks (level 2). For chronic low back pain, the evidence shows that various types of nonsteroidal antiinflammatory drugs are equally effective or ineffective, and that antidepressants provide no benefit in the short to intermediate term (level 2). Muscle relaxants showed limited effectiveness (level 3) for chronic neck pain and for chronic low back pain for up to 4 weeks. For fibromyalgia, there is limited evidence (level 3) of the effectiveness of amitryptiline, ondansetron, zoldipem, or growth hormone, and evidence of no effectiveness for nonsteroidal anti-inflammatory drugs, malic acid with magnesium, calcitonin injections, or s-adenyl-L-methionine. For temporomandibular pain, oral sumatriptan is not effective (level 2). The remaining evidence was inadequate (level 4a) or contradictory (level 4b).
Previous meta-analyses have been conducted to compare outcomes of various treatment injections for lateral epicondylitis (LE), including corticosteroid injection (CSI) and autologous blood products such as autologous blood (AB) and platelet-rich plasma (PRP).
PURPOSE:
To conduct a systematic review of overlapping meta-analyses comparing different injection treatments (CSI, AB, PRP) for LE to determine which meta-analyses provide the best available evidence.
STUDY DESIGN:
Systematic review; Level of evidence, 2.
METHODS:
A systematic review was performed by searching PubMed, Embase, and the Cochrane Library to locate meta-analyses that compared clinical outcomes of CSI, AB, and PRP for the treatment of LE. Search terms included "injection," "corticosteroid," "platelet-rich plasma," "autologous blood," "tennis elbow," "lateral epicondylitis," and "meta-analysis." Results were reviewed to determine study eligibility. Patient outcomes were extracted from these meta-analyses. Meta-analysis quality was assessed with the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence.
RESULTS:
Nine meta-analyses (two level 1 studies, seven level 2 studies) containing 8656 patients met the eligibility criteria. Seven meta-analyses found that autologous blood products such as AB and PRP significantly improved pain and elbow function in the intermediate term (12-26 weeks), while 4 studies found that CSI effectively relieved pain and improved elbow function in the short term (<12 weeks). The study by Arirachakaran et al in 2016 received the highest QUOROM and Oxman-Guyatt scores; therefore, this meta-analysis appears to have the highest level of evidence. In addition, this study was rated the highest-quality study in this systematic review according to the Jadad decision algorithm. Lower-quality meta-analyses indicated that dosage, number of injections, and differences in therapeutic duration between CSI and autologous blood products may be essential factors in determining the appropriate treatment injection protocol for LE.
CONCLUSION:
The current best available evidence suggests that CSI improves functional outcomes and pain relief in the short term, while AB and PRP are the most effective treatments in the intermediate term.
